Preliminary Care Plan for Stroke and Depression Patient

Type: Assignments

Subject: Community Health Nursing

Subject area: Nursing

Education Level: Undergraduate/College

Length: 3 pages

Referencing style: APA

Preferred English: US English

Spacing Option: Double

School: Capella University

Title: Coordinated Patient Centered Care

Preliminary Care Plan for Stroke and Depression Patient

Cardiovascular accident (commonly referred to as stroke) is a highly debilitating condition that leads to considerable morbidity and mortality. Cardiovascular accidents (CVAs) are primarily classified into hemorrhagic or ischemic CVAs, the former being the most common (80%). The remaining 20% of cases occur as ischemic strokes. Each year, the USA experiences approximately 795,000 cases of stroke, ranked as the 5th leading cause of disease mortality while contributing to the highest level of adult disability (Boehme et al., 2017). This leads to considerable social, economic, and physical effects that impair an individual's daily living functions and cause poor productivity. The paper below will analyze the case study of a 67-year-old stroke patient who was discharged after 2 weeks to a skilled nursing facility. The patient also has comorbidities such as diabetes, hyperlipidemia, hypertension, and depression. Several episodes of poor adherence to medication were also reported. Apart from describing the presenting condition (stroke), the analysis will also develop interventions with SMART goals for the patient. 

Stroke is an acute condition that leads to alteration in vascular blood flow and impaired cerebral perfusion due to either impediment of blood supply (ischemic) or due to the rupture of blood vessels (hemorrhagic). Ischemic strokes can further be classified into lacunar, atherosclerotic, cardio-embolic, and other specific subtypes (e.g., vasculitis and dissection subtypes). On the other hand, hemorrhagic stroke is classified into subarachnoid or intraparenchymal subtypes. Some of the modifiable risk factors for stroke include a poor diet, hypertension, hyperlipidemia, diabetes, sedentary lifestyle, infections, cigarette smoking, and heart diseases (e.g., infective endocarditis, congestive heart failure, and atrial fibrillation). Non-modifiable risk factors include genetics, race (higher risk among Asians and Afro-Carribeans), age, male gender, and previous vascular events (e.g., CVA, peripheral vascular disease, and myocardial infarction) (Boehme et al., 2017). The manifestations of a stroke depend entirely on disease severity and the areas affected. This leads to manifestations such as loss of motor functions, visual impairment, ataxia, dysarthria, flaccid paralysis, and many others. Some of the complications include aspiration pneumonia, depression, deep venous thrombosis, seizures, pressure sores, pulmonary embolism, fall injuries, bladder dysfunctions, and anxiety (Kim et al., 2017). 

The case study presents Mr. Smith, A 67-year-old widowed African-American who also lives alone. Apart from a stroke, Mr. Smith was also diagnoses with different comorbidities, including diabetes, hyperlipidemia, hypertension, and depression. This necessitates the development of multidisciplinary interventions with proper follow-up and continuity of care. Some of the main areas that will be addressed in Mr. Smith's treatment plan include reduction of risk factors for stroke, mitigation of complications such as depression, and reduction of loss of function. Thus, the different interventions that will be developed will revolve around these three aspects.

 The first intervention is geared toward risk modification. Some of the identifiable risk factors that may lead to recurrent stroke in the patient include hypertension, hyperlipidemia, and diabetes mellitus. The health clinicians can adopt both pharmacologic and non-pharmacologic interventions for these risk factors. An increase in age leads to a proportional increase in blood pressure levels in individuals. As such, two-thirds of individuals aged 65 years and above have high higher than normal blood pressure levels. (Boehme et al., 2017). From the case study, Mr. Smith needs to be put on effective antihypertensive, which will help maintain blood pressure levels below 130/80 mmHg (therapeutic level). An effective antihypertensive would be atenolol (a beta-blocker) at 25 mg daily, followed by the cardiologist's periodic reviews. 

Mr. Smith will also participate in lifestyle modifications such as exercises (e.g., 30 –minute brisk walks) and proper diet. Some of the diet changes that need to be executed include low sodium intake, a DASH diet plan (consists of a diet rich in whole grains, vegetables, fruits, and low-fat dairy products), and potassium supplementation (Whelton et al., 2018). The progress in adherence to the dietary plan can also be followed up by the nutritionist. Apart from diet, Mr. Smith should also participate in structured physical activities that promote weight loss. Since the patient has hemiparesis, assistive devices such as walking frames and walking sticks can be utilized (Boehme et al., 2017). The exercise intensity should range from moderate to intense exercise activities. Mr. Smith should participate in at least 3 sessions every week. This will help in the modification of hypertension, hyperlipidemia, and diabetes. The physical therapist will facilitate the development of participation in exercise activities while the nutritionist will participate in developing the most appropriate meals. Exercise in stroke patients also offers mood and cognitive benefits, thus lowering the impact of depression and anxiety symptoms. 

The next intervention is aimed at promoting the level of coping in the patient. This is directed towards the reduction in the patient's depressive symptoms. The case study presents Mr. Smith, who has been experiencing symptoms of depression after his spouse's death one year ago. A stroke's pathological process may have aggravated these depressive symptoms through brain injury (Towfighi et al., 2017). Therefore, Mr. Smith will benefit from psychosocial interventions such as cognitive-behavioral therapy (CBT) and social support (Towfighi et al., 2017). CBT is aimed at changing the patient’s belief patterns and eliminating negative self-appraisal by identifying cognitive distortions. Some of the cognitive distortions that may be expressed in Mr. Smith include overgeneralization, guilt, and self-blame. CBT will also improve Mr. Smith's adherence to treatment, which will promote desirable health outcomes. Linkage to a psychiatrist will help maintain and assess the success of the proposed interventions, thus promoting continuity of care.

The final intervention is aimed at improving Mr. Smith's level of physical mobility and the execution of activities of daily living. One of the most effective intervention is muscle training for both upper limbs and lower limbs. Lower limb muscle training can be executed through interventions such as the use of treadmills training, pedaling/cycling, walking, bilateral leg-press, and the use of electromechanical gait training. Treadmill training can be conducted either independently by the patient or through support from the healthcare provider. These groups of exercises will help in improving Mr. Smith's gait, mobility, and body support/balance. Upper limb muscle exercises may include repetitive task training. Some of the target activities include manipulation, moving, pointing, reaching, and grasping objects in a task-oriented manner. All the above muscle exercises will help improve Mr. Smith’s activities of daily living (ADL). Finally, linkage to a physical therapist who is easily accessible in the community will help in ensuring continuity of care for Mr. Smith. 

The above interventions can be summarized through SMART goals, which will be developed in collaboration with the client and the family. The SMART will guide the implementation of the interventions through continuous monitoring and evaluation. As such, the clinician should participate in continuous monitoring and assessment to ensure that Mr. Smith meets the desired outcomes. 

• Goal 1: To develop a low risk of stroke by controlling hypertension and hyperlipidemia drug treatment, diet modifications, and physical activity within 1 month.
• Goal 2: To reduce depressive symptoms in Mr. Smith through cognitive behavioral therapy within 1 month. 
• Goal 3: To improve muscle strength in Mr. Smith through muscle training within 3 months.

References 

Boehme, A. K., Esenwa, C., & Elkind, M. S. (2017). Stroke risk factors, genetics, and prevention. Circulation Research, 120(3), 472–495. https://doi.org/10.1161/CIRCRESAHA.116.308398

Kim, B. R., Lee, J., Sohn, M. K., Kim, D. Y., Lee, S. G., Shin, Y. I., Oh, G. J., Lee, Y. S., Joo, M. C., Han, E. Y., & Kim, Y. H. (2017). Risk factors and functional impact of medical complications in stroke. Annals of Rehabilitation Medicine, 41(5), 753–760. https://doi.org/10.5535/arm.2017.41.5.753

Towfighi, A., Ovbiagele, B., El Husseini, N., Hackett, M. L., Jorge, R. E., Kissela, B. M., ... & Williams, L. S. (2017). Poststroke depression: A scientific statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 48(2), e30-e43. https://doi.org/10.1161/STR.0000000000000113

Walker, B. R., Colledge, N. R., Ralston, S. H., & Penman, I. D. (2014). Davidson's principles and practice of medicine. New York: Elsevier. 

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., ... & MacLaughlin, E. J. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248. https://doi.org/10.1161/HYP.0000000000000065